Invisible Populations, Visible Outcomes: A Linked-Data Study of Homelessness, Mental Health, and Inclusion-Health Pathways in Dhaka

Homelessness contributes to poor mental health, lack of social supports and lack of connection to health services. This is a significant problem of inclusion in health services, and little is known about the pathways taken by adults who are living in homelessness in Dhaka through health services, or why many drop-out of services. This study looked at trends in mental health service use, emergency/crisis-service use, referral completion and continuity of care, as well as experiences that influenced these trends. The design was a sequential mixed-method explanatory. In the quantitative phase, 300 adults who are experiencing homelessness in Dhaka participated. Descriptive statistics was used to analyze the data, chi-square test, and multivariable logistic regression were used to analyze the data. The second phase of the study, the qualitative phase, involved conducting 20 semi-structured interviews with service users and 12 frontline staff, which were analysed using descriptive thematic analyses. It was found that 68.0% of the participants experienced mental distress or emotional distress at the present time or recently and 63.0% indicated that they had an unmet need for mental health support. Fewer than half (39.0%) had been to a mental health service and nearly half (59.0%) had attended an ED. The majority of the participants (73.0%) had poor continuity of care. Poor continuity was associated with longer homelessness, substance use problems, and limited social support, as well as to not being able to identify as a citizen. There was a correlation between improved continuity and outreach contact and formal referral. These patterns were described by six themes of the qualitative analysis: Survival pressure, Stigma, Broken referrals, and Unsafe discharge. The results indicate that there is a need to enhance outreach, active referral, flexibility when registering, and coordination of services across health, housing and social services in order to increase continuity and decrease use of crisis care.